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TSYS Payment Acceptance Products <br />Merchant # DBA Name (. /iy Gellfx X, <br />Date (!�% /Y/ 0� Sales Rep Ext. <br />Parent MID: E -mail: ICI Al1 a_tnckc. 66a,- a- -Onct , 0 <br />(Enter in POS Notes) (Enter in POS Notes) <br />TSYS Payment Acceptance: <br />CounterPASS _ <br />WebPASS <br />Mu1tiPASS <br />Additional MIDs under Parent: Yes <br />(Please list additional MIDS on attached sheet) <br />Parent MID <br />Activation Fee (per MID): $�_ <br />Commen <br />No—Z <br />Monthly Fee (per MID): $�_ <br />bV� C, <br />Merchant Advocate Name Merchant ame <br />Authorized Signature <br />Print Name <br />Title <br />Date <br />201405 <br />ATTEST', <br />piAAR9A D. dilDlXkt <br />CLERK OF THE FII c;OUNiCIL <br />